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Peds Flashcards

1
Q

What is Pierre Robin sequence associated with?

A

Micrognathia, glossoptosis, airway obstruction

  • must used supraglottic airway on induction
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2
Q

How do you induce a child with Pierre Robin?

A

With sevoflurane to maintain spontaneous ventilation

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3
Q

What are the conditions associated with the Pierre Robin sequence

A

Treacher-Collins
FAS
Velocardiofacial
Stickler

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4
Q

What does velocardiofacial look like?

A 
Long face
Dark circles under eyes
Prominent nose
Flattened cheeks
Cardiac and palatal anomalies
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5
Q

What is congenital emphysema?

A

Hyperinflation of one area of the lungs with ball-valve effect

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6
Q

How should a patient with congenital emphysema be induced and why?

A

With sevoflurane and maintain spontaneous ventilation.
NO nitrous do to increase of bleb and subsequent PTX
NO positive pressure as in controlled ventilation

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7
Q

What are the primary mediators of nonshivering thermogenesis in infacts and neonates?

A

Norepinephrine
Thyroxin
glucocorticoids

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8
Q

How does nonshivering themogenesis work?

A

The cold stimulates norepinephrine release which stimulates B receptors in brown fat which uncouples oxidative phosphorylation to make heat instead of ATP through lipase –> release of fatty acids

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9
Q

What inhibits nonshivering thermogenesis?

A

Inhalational anesthetics

Beta blockers

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10
Q

How does GFR differ in neonates?

A

It is lower

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11
Q

When does GFR increase in neonates?

A

At 3-5 weeks when the nephron ages

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12
Q

What is different about the neonate nephron?

A

The distal tubule cannot absorb sodium because they are resistant to aldosterone.
The collecting tubule is resistant to ADH - cannot hold onto water or sodium!

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13
Q

What is the total body water of a child compared to an adult?

A

Larger TBW so more sensitive to dehydration

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14
Q

What is the body surface area to body weight ratio of a pediatric patient compared to an adult?

A

Much higher so more evaporative losses

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15
Q

How do the neonate heart differ from the adult heart?

A

It is relatively noncompliant with decreased intracellular calcium stores and therefore decreased contractility, so SV is fixed. CO depends solely on HR.

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16
Q

Why else is dehydration dangerous in a child?

A

Because they cannot compensate as well with heart rate due to PNS predominance and immature baroreceptor reflexes

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17
Q

What is the equation for maintenance fluid?

A

4 ml/kg/hr for the first 10 kilograms
2 ml/kg/hr for the second 10 kg
1 ml/kg/hr for anything over 20 kg

***If child is over 20 kg just add 40 to the weight

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18
Q

What is the equation for NPO deficit?

A

Number of hours NPO X maintenance fluid

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19
Q

How do you replace the child’s fluid deficit?

A

Replace the first half in the first hour of surgery, then one quarter in the second hour, then the last quarter in the third hour

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20
Q

When should blood be the replacement fluid?

A

When EBL = 20% of blood volume lost because the amount of crystalloid it takes to keep up goes up exponentially

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21
Q

What are patients with Duchenne’s muscular dystrophy at risk for under anesthesia?

A
  1. Cardiac dysrhythmias due to imbalance of PNS/SNS and the fibrosis of the conduction system associated with this dz.
  2. Hyperkalemia and rhabdo due to inhalational anesthetics which disrupt cells and cause an increase in intracellular calcium
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22
Q

What are patients with myotonic dystrophy in danger of?

A

Severe myotonias that can be caused by anesthetic drugs such as: succinylcholine, acetylcholinesterase inhibitors (neostigmine), potassium containing solutions

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23
Q

What is myotonic dystrophy?

A

Autosomal dominant disease causing muscle weakness and contractures

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24
Q

What is the first sign of intrathecal injection on a child under 5 years of age?

A

Apnea

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25
Where does the dural sac end in newborn?
S2-3
26
Where is the site of injection of caudal anesthesia?
S4-5
27
What is the chance of an infant having a PTX after meconium aspiration?
10%
28
What are the clinical signs of neonatal PTX?
Hyperexpansion Poor excursion Muffled heart sounds
29
What is the treatment for neonatal PTX?
22G at 2nd intercostal space, midclavicular line for emergent decompression
30
What is the appropriate bolus dose of IVF for a hypovolemic pediatric patient?
20 ml/kg of isotonic solution
31
What can you give the hypovolemic child who is not responsive to a crystalloid bolus?
10 ml/kg salt-poor albumin
32
What is the best indicator that a patient is optimized after pyloric stenosis for surgery?
Normal chloride because they have hypokalemia hypochloremic metabolic alkalosis due to vomiting HCL
33
When does surfactant production occur?
By type II pneumocytes after 32 weeks gestation
34
What are the clinical manifestations of RDS?
Grunting Nasal flaring Chest retractions
35
What is the pathophysiology of RDS?
Decreased surfactant which causes decreased compliance of the lungs, instability at the end of expiration, and low lung volumes as well as increased inflammation and pulmonary edema. It creates an intrapulmonary shunt and V/Q mismatch leading to hypoxia
36
What is the treatment for RDS?
Exogenous surfactant
37
What indicates mature fetal lungs?
A lecithin : sphingomyelin ratio > 2.0 or 3.5 in diabetics
38
When is lecithin made in the gestational period?
between 24-26 weeks
39
When are lecithin and sphingomyelin about equal?
32-33 weeks
40
When does lecithin increase in gestation?
35 weeks
41
How does hepatic metabolism compare to adults in neonates?y
It is much slower so you have increased duration of action of NMBs that are hepatically meatbolized (vec, roc)
42
When is there complete maturation of the NMJ?
2 months - diaphragm is paralyzed at the same time as other muscles
43
What are the risk factors for postop OSA after adenotonsillectomy?
``` Age < 3 years history of prematurity URI in the past 4 weeks Obesity High Mallampati score Nasal abnormalities Obstruction with inhalational induction HTN, cor pulmonale Difficulty breathing in sleep Disorderd breathing in PACU Craniofacial and neuromuscular disorders ```
44
Why do babies have a higher respiratory rate?
They have high chest wall compliance making work of breathing harder because they cannot maintain negative intrathoracic pressure therefore they have functional airway close with every breath
45
What is the first step when dealing with acute epiglottitis?
Take to the OR and do an inhalational induction with surgical back up May use minimal PEEP Use tube 1-2 smaller than usual
46
What is hypoplastic LH associated with?
ASD Stenotic or atretic MV Hypoplastic ascending aorta
47
What does survival depend on with hypoplastic left heart?
PDA (flow from pulm to aorta)
48
What does coronary circulation depend on in hypoplastic left heart?
PDA
49
How is blood delivered and oxygenated in hypoplastic LH?
It enters the right atrium and crosses into the left atrium via ASD mixing with oxygenated blood. Returns to the right ventricle where the semi-mixed blood is ejected into the pulmonary artery to go to the lungs and through the PDA to go to the systemic circulation
50
What is the dose of oral midazolam for children?
0.5-1 mg/kg
51
What are the side effects of midazolam in children?
Nightmares Fearfulness Food rejection Occurs within 1 week post op and resolves itself in 2 weeks
52
What happens during a "Tet" spell?
Increased pulmonary vascular resistance shunts blood through VSD and into systemic circulation
53
What are the cardiac lesions in TOF?
VSD Overriding aorta Infundibular pulmonary stenosis RVH
54
Why do cyanotic spells happen in TOF?
Right to left shunting due to RVOT obstruction from pulm. stenosis
55
What should be avoided in TOF?
Anything that increases pulmonary vascular resistance - hypoxia, hypercarbia, acidosis, pain, stress
56
What is a Blalock-Taussig procedure?
Graft from the left or right subclavian artery to the ipsilateral pulmonary artery.
57
Why is IV induction faster with TOF?
Because the VSD allows shunting of blood from the pulmonary system straight to the systemic
58
What medication can be used to relieve RVOT obstruction from infundibular spasm?
Propanolol
59
What is the drug of choice when patient is having a Tet spell during anesthesia?
Phenylephrine to increase systemic vascular resistance and thereby decrease right-to-left shunting
60
What is the most effective method to treat intraoperative hypothermia of a peds patient?
Forced air blanket
61
When is the optimal leak pressure?
20-30 cm H2O
62
What is the danger with leak pressure above 30 cm H2O?
Higher risk for tracheal ischemia, post intubation croup, TE fistula formation, tracheal stenosis, tracheomalacia
63
What is the equation for ETT choice?
Age + 16/4 | Go down 1/2 size for cuffed tube
64
What are the considerations with Down's patient?
Subglottic narrowing and smaller trachea size may require smaller tube Paradoxical bradycardia or profound tachycardia to atropine and inhalational induction
65
What is the EBV of a full term newborn?
80-90 ml/kg
66
What is the EBV of a premature infant?
90-105 ml/kg
67
What is the EBV of an infant 3-12 months old?
70-80 ml/kg
68
What is the EBV of a child 1-12 years old?
70-75 ml/kg
69
What is a common side effect of PGE1?
Apnea | Other side effects: fever, flushing, bradycardia, gastric outlet obstruction, CNS irritability
70
What is the action of PGE1?
Direct-acting vasodilator via prostanoid receptors on the vascular smooth muscle of ductus arteriosus. Decrease pulmonary vascular ressistance Decrease SVR
71
What is the physiology by which the PDA closes after birth?
Lung expansion and increased alveolar oxygen tension lead to decrease in PVR which leads to flow reversal in the ductus arteriosus. Decreased PGE1 results in mechanical closure within 1-2 days. Anatomic closure happens within a few weeks.
72
What is pulmonary atresia?
Underdevelopment of the RVOT causing resistance of flow toward the pulmonary vasculature
73
What is the first stage in correction of pulmonary atresia?
modified Blalock-Taussig
74
What medication is contraindicated in post-tonsillectomy patients?
Codeine - FDA blackbox about pediatric deaths
75
What is Klippel-Feil is associated with?
Fusion of the cervical spine
76
What is Beckwith-Weidemann syndrome associated with?
Macroglossia, organomegaly, hypoglycemia
77
What are the blood:gas partition coefficients of inhalation anesthetics in infants compared to adults?
They are lower therefore leading to a faster rise in Fa:Fi ratio and faster induction
78
What is the most important factor for speed of induction of infants?
The increased minute ventilation to FRC
79
What concentration of dextrose in LR solution actually increases mortality?
5% because it causes hyperglycemia in the perioperative period at maintenance rates
80
What is the most effective medication for PONV in children?
Zofran
81
What are the risks of PONV in children?
``` Age > 3 yo Duration of surgery (>30 minutes) Type of procedure (strabismus repair, T&A) History of PONV Family history of PONV ```
82
When does the risk of PONV change with sex?
Males have the same risk as females until puberty
83
How much dexamethasone is used for PONV?
0.15 mg/kg
84
What is the dosage of zofran for ped?
0.1-0.15 mg/kg
85
What is the studied propofol dosage for PONV?
1 mg/kg bolus + 20 mcg/kg/min infusion
86
What does increased CO do to speed of inhalational induction?
It will decrease the speed of inhalational induction due to uptake of the anesthetic gas and slower rise of Fa:Fi ratio
87
What are patients with strabismus who receive succinylcholine at higher risk for?
Masseter muscle rigidity
88
What are the risk factors of postoperative apnea in infants?
``` Prematurity Regional anesthesia with sedation History of apnea and bradycardia Anemia (Hct < 25-30%) Post conceptual age less than 60 weeks, especially 42-44 weeks ```
89
At what age should elective surgical procedures be postponed?
Until at 44-60 weeks if they have no history of apnea or bradycardia.
90
What are the clinical signs of mild dehydration in a newborn?
``` 5% weight loss Normal skin turgor Moist mucous membranes Urine <2 ml/kg/hr Urine specific gravity < 1.020 ```
91
What are the clinical signs of moderate dehydration in a newborn?
10% weight loss Decreased skin turgor Dry mucous membranes Urine flow <1 ml/kg/hr
92
What are the clinical signs of severe dehydration in a newborn?
``` 15% weight loss Very dry mucous membranes Urine < 0.5 ml/kg/hr Rapid weak pulse Reduced blood pressure Deep and rapid respirations Decreased level of consciousness Decreased muscle tone Cold, Sweaty, gray ```
93
Why is there a slower redistribution of heat from the core to the periphery in children than in adults?
Because they have smaller limb size and greater proportion of body mass contained in the core compartment.
94
Where is brown fat located?
Posterior neck Interscapular region Vertebral areas Around kidneys and adrenals
95
What are the intraoperative goals for a neonate with diaphragmatic hernia?
Permissive hypercapnia SaO2 85-95% Spontaneous respiration PIP < 25 cmH2O
96
Why do patients with pyloric stenosis have metabolic alkalosis?
They lose chloride rich gastric fluid through vomiting and bicarb is exchanged in the stomach for chloride ions, so serum bicarb is increased due to increased gastric absorption.
97
What is the most commonly associated condition with TE fistulas?
Congenital heart defects
98
What does VACTERL stand for?
Vertebral, Anal, Cardiac, Tracheal, Esophageal, Renal , Limb
99
What medication has proved effective in reducing postintubation croup?
Dexamethasone 0.5 mg/kg IV with max of 10 mg
100
What are the most common cause of postintubation croup?
Subglottic injury or edema Traumatic intubation Oversized ETT Overinflated ETT cuff
101
What do you treat mild postintubation croup with?
Cool, humidified mist
102
What is the treatment of moderate-severe postintubation croup?
Nebulized, racemic epi (0.5 ml of 2.25%, diluted in 3-5 ml )
103
If an infant has a history of apnea and bradycardia, what is the best time to perform elective surgery?
6 months from the apneic/bradycardic episode regardless of age.
104
What is an independent risk factor for apnea?
Anemia
105
What is gastroschisis?
Exposure of bowel with no enclosing membrane typically to the right of the umbilical cord - high incidence of heat loss and infection
106
Which is worse - gastroschisis or omphalocele?
Omphalocele because it is associated with other anomalies such as Beckwith-Weidemann, Reiger, trisomies
107
What is gastroschisis associated with in the mother?
Young maternal age | Maternal exposure to smoking, illicit drugs and APAP, ASA and Pseudoephedrine
108
What is omphalocele associated with in the mother?
Advanced maternal age

Anesthesia MM/TL (36 decks)

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